850 The International Journal of Tuberculosis and Lung Disease
2 World Health Organization. Rapid implementation of Xpert MTB/RIF diagnostic test. Technical and operational ‘how-to’ practical considerations. WHO/HTM/TB/2011.2. Geneva, Swit-zerland: WHO, 2011. http://whqlibdoc.who.int/publications/ 2011/9789241501569_eng.pdf Accessed April 2013.
3 Sandman L, Schluger N W, Davidow A L, Bonk S. Risk factors for rifampin-monoresistant tuberculosis: a case-control study. Am J Respir Crit Care Med 1999; 159: 468–472.
4 Mukinda F K, Theron D, van der Spuy G D, et al. Rise in r ifampicin-monoresistant tuberculosis in Western Cape, South Africa. Int J Tuberc Lung Dis 2012; 16: 196–202.
5 Mirsaeidi S M, Tabarsi P, Khoshnood K, et al. Treatment of mul-tiple drug-resistant tuberculosis (MDR-TB) in Iran. Int J Infect Dis 2005; 9: 317–322.
Improvement in tubercular cavities following adjuvant treatment with endobronchial valves: a case report
In 2010, multidrug-resistant tuberculosis (MDR-TB) occurred in 650 000 of the 12 million TB cases world-wide,1 with extensively drug-resistant (XDR) TB
com-prising 9% of the MDR-TB cases.2 Treatment success
is between 44% and 60%.3 We hypothesised that a
recent form of lung collapse therapy—the insertion of Zephyr® endobronchial valves (EBVs; Pulmonx,
Redwood, CA, USA)—may be effective in the treat-ment of MDR/XDR-TB. This minimally invasive pro-cedure is usually indicated for reducing emphysema-associated hyperinfl ation.4 The one-way valve allows
air and secretions to leave the lobe, but prevents air from entering, bringing about lobar collapse.
A 29-year-old female patient was admitted for treatment for XDR-TB in January 2011. She had been diagnosed with MDR-TB in Romania in 2006, with a further relapse in 2009. In 2011, the diagnosis was changed to XDR-TB. She was considered ineli-gible for surgery due to extensive disease.
Sputum culture recorded heavy growth of
Myco-bacterium tuberculosis. A computed tomography (CT)
scan (26 January 2011) showed multiple cavities in the left lower lobe, left upper lobe (LUL), right mid-dle lobe (RML), and right lower lobe.
Based on the results of drug susceptibility testing, treatment was initiated in January 2011 with intra-venous imipenem/cilastatin, amikacin, linezolid and
oral clofazimine. The patient showed no improvement in asthenia, persistent coughing, intermittent fever or haemoptysis. Continuous evaluation by sputum anal-ysis and CT (March 2011) showed no improvement. Given the patient’s deteriorating condition, we considered EBV placement. Pre-treatment CT was performed (Figure 1A). On 19 May 2011, two 4-mm Zephyr® valves were inserted into the lateral and
medial segmental bronchi of the middle lobe bron-chus under local anaesthesia and conscious seda-tion. On 27 May 2011, terizidone was added to the treatment.
A follow-up CT at 1 month (Figure 1B) showed a marked reduction in the size of the RML cavity. However, sputum culture remained positive. The fi rst negative culture was obtained in a sample on 21 Sep-tember. Treatment with TMC207 (an experimental drug) was commenced on 1 October. In October, the direct sample was sporadically positive. At the end of October, both sputum smear and culture became de-fi nitively negative. A CT scan in November 2011 (not provided) showed resolution of the RML cavity.
On 11 January 2012, in a single procedure, the two EBVs were removed from the RML, and a 5.5-mm Zephyr® valve was placed in the apicoposterior branch
of the LUL where a cavity persisted (Figure 2A). Follow-up CT at 1 month showed that the cavity in the LUL had reduced in size (Figure 2B). The patient was now asymptomatic.
A recently conducted 10-month follow-up CT (Oc-tober 2012) demonstrated a further reduction in the size of the LUL cavity (Figure 2C) and stability of the RML (Figure 1C). Sputum smear and culture r emained negative. The remaining EBV was subse-quently removed.
We hypothesised that using Zephyr® EBV to
cre-ate hypoventilation and hypo-oxygenation of the lung lobe would promote healing of the tubercular cavity. In our case, Zephyr® EBV placement resulted
in reductions in cavity size in each of the treated lobes within 1 month. Sputum smear and culture became negative 5 months after EBV placement. No EBV-r elated complications occuEBV-rEBV-red.
To our knowledge, our case provides the only
Figure 1 Chest CTs clearly showing changes in the cavity in the RML. A. Pre-treatment CT scan (May 2011) clearly showing the
cavity (2.0 × 1.1 cm) in the RML (arrow). B. 1-month follow-up CT scan (June 2011) showing resolution of the cavity (arrow) and the two EBVs in place (arrowheads). Of note, there was a spontaneous reduction in the size of a cavity in the LUL (from 3.2 × 1.9 to 2.1 × 1.5 cm), which was later targeted (see Figure 2). C. 17-month follow-up CT scan (October 2012) demonstrating stability of the RML after removal of the EBVs. CT = computed tomography; RML = right middle lobe; EBV = endobronchial valve.
Correspondence
851
radio graphic evidence supporting the effectiveness of EBVs in closing tubercular cavities. The only other reports on a similar technique are from Russia,5
where improvement in the tubercular process was re-ported in 89 patients with MDR-TB and 118 patients with infi ltrative pulmonary TB.
More detailed information on this case (clinical outcomes and high-resolution fi gures) can be obtained from the corresponding author upon request.
Prof. Lorenzo Corbetta* Dr. Flavio Montinaro†
Dr. Pier Giorgio Rogasi‡
Dr. Fabrizio Luppi§
Dr. Chiara Magni* Dr. Simona Paiano* Dr. Ariela Tofani* Prof. Massimo Pistolesi¶
*Unit of Diagnostic and
Interventional Bronchology † Unit of Thoracic Surgery ‡ Unit of Infectious Diseases Careggi University Hospital
Florence § Unit of Respiratory Disease University Hospital
Modena
¶ Section of Respiratory Medicine Department of Internal Medicine Careggi University Hospital Florence
Italy e-mail: lorenzo.corbetta@unifi.it http://dx.doi.org/10.5588/ijtld.12.0992 Acknowledgements
The authors gratefully acknowledge the translation and editing support received from Archimed Medical Communication Ag, Zo-fi ngen, Switzerland. This publication was supported by Pulmonx.
Confl ict of interest: none declared. References
1 World Health Organization. Global tuberculosis control, 2011. Geneva, Switzerland: WHO, 2011.
2 Chang K C, Yew W W. Management of diffi cult multidrug-r esistant tubemultidrug-rculosis and extensively dmultidrug-rug-multidrug-resistant tubemultidrug-rculo- tuberculo-sis: update 2012. Respirology 2013; 18: 8–21.
3 Kim H R, Hwang S S, Kim H J, et al. Impact of extensive drug resistance on treatment outcomes in non-HIV-infected patients with multidrug-resistant tuberculosis. Clin Infect Dis 2007; 45: 1290–1295.
4 Sciurba F C, Ernst A, Herth F J, et al. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med 2010; 363: 1233–1244.
5 Levin A V, Tseikhmakh E A, Zimonin P E. The use of valvular bronchial blocking in complicated lung tuberculosis. Barnaul, Russia: Medlung, 2008. www.medlung.ru/downloads/manuals/ medlung-eng.pdf Accessed April 2013.
Figure 2 Chest CTs clearly showing changes in the cavity in the LUL. A. CT scan 2 months before second EBV implantation
(November 2011). The size of the cavity in the LUL had remained stable (2.1 × 1.2 cm) since the CT scan taken in June 2011 (see Figure 1B). B. 1-month follow-up CT scan (February 2012) showing a reduction in the size of the cavity (1.7 × 1.0 cm) in the LUL (arrow). C. 10-month follow-up CT scan (October 2012) showing resolution of the cavity (EBVs still in place). CT = computed t omography; LUL = left upper lobe; EBV = endobronchial valve.
ERRATA
IN THE ARTICLE entitled ‘Time to act to prevent and control tuberculosis among inmates’ by M. Dara, S. S. Chadha, N. V. Melchers, J. van den Hombergh, E. Gurbanova, H. Al-Darraji, J. B. W. van der Meer (Int J Tuberc Lung Dis 2013; 17(1): 4–5; http://dx.doi.org/10.5588/ijtld.12.0909), the name of author N. V. Melchers should have read N. V. S. Vinkeles Melchers, and her affi liation should have read: Aca-demic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands. [http://dx.doi.org/10.5588/ijtld.12.0909-e]
IN THE ARTICLE entitled ‘Trends in the annual risk of tuberculous infection in India’ by V. K. Chadha, R. Sarin, P. Narang, K. R. John, K. K. Chopra, R. Jitendra, D. K. Mendiratta, V. Vohra, A. N. Shashidhara, G. Muniraj, P. G. Gopi, P. Kumar (Int J Tuberc Lung Dis 2013; 17(3): 312–319; http://dx.doi.org/10.5588/ ijtld.12.0330), the affi liation for G. Muniraj should have read Department of Community Medicine, Christian Medical College, Vellore, Tamil Nadu. [http://dx.doi.org/10.5588/ijtld.12.0330-e]
